Diagnostic and infection control strategies for Clostridioides difficile infections in a setting of high antimicrobial resistance prevalence.

Clostridioides difficile (CD) is a major nosocomial pathogen and the leading cause of antibiotic-associated diarrhoea. In light of the strong association between antimicrobial use and CD infections (CDI), it may be hypothesised that areas at higher prevalence of antimicrobial resistance, like the region of Campania in southern Italy, could also have a higher rate of CDI. In this multicentre, region-based, prospective study, we analysed such issues, exploiting CDI incidence data collected from local hospitals. In 2016, the Italian National Centre for Disease Control supported a project involving three Italian regions: Friuli Venezia Giulia, Lazio and Campania. In Campania, a network of 49 hospitals willing to participate in the project was created. The project consisted of two phases: a survey on practice patterns concerning CDI and an epidemiological surveillance study. We identified a stringent need to improve awareness about CDI among the regional health-care community, as a widespread lack of surveillance programmes for CDI control was observed (existing in only 40% of participating facilities). Moreover, almost half of the participating hospitals (n=16, 43%) had no standardised procedures or protocols to control and prevent CDI. In the second phase of the study, we collected data of CDI cases during a six-month surveillance programme. In all, 87 CDI cases were observed, for a total of 903,334 patient bed-days and 122,988 admissions. According to the above data, CDI incidence was 0.96 cases/10000 patient bed-days, much lower than expected based on prior studies conducted elsewhere. The results of our study suggest CDI remains a rather neglected clinical issue in Campania. Despite a high burden of antimicrobial resistance and antimicrobial use in our geographic setting, we observed a very low incidence of CDI. Such a low incidence could be explained by underdiagnosis, but could also be related to actual diet, the lower patient age or the specific genetic background. However, further studies are warranted to either confirm or rebut the above hypotheses.

Knowledge, attitudes, and practices of General Practitioners from the Province of Parma (Northern Italy) towards vaccinations in adults ≥ 65 year-old.

BACKGROUNDS AND AIMS: This study aims to characterize attitudes and knowledge towards immunization practice of people aged >65 years for seasonal influenza (SIV), pneumococcus (PNV), and Herpes zoster (ZV) in a sample of Italian general practitioners (GPs). MATERIALS AND METHODS: During 10/2018, a structured questionnaire was emailed to 274 GPs operating in the Province of Parma, Italy. Association between willingness to perform aforementioned vaccines and individual factors was assessed through a multivariate regression analysis by calculating multivariate Odds Ratio (mOR). RESULTS: A total of 73 GPs (26.6% of original sample) completed the questionnaire. Knowledge gaps were identified on the targeted vaccination rates for PNV and ZV (31.6% and 21.9% of correct answers), on the formulation of VZ (41.1%), and on the simultaneous immunization SIV/ZV (12.3%). The majority of respondents had high/very high trust on safety and efficacy of assessed vaccines. In multivariate analysis, recommending PNV was associated with having previously received SIV (mOR 5.44, 95%CI 1.08-27.31). In turn, ZV was negatively associated with a self-assessed knowledge gap (mOR 0.07, 95%CI 0.01-0.63). DISCUSSION: Despite a generally favorable attitude towards vaccines, GPs exhibited knowledge gaps deserving appropriate intervention. However, lack of association between knowledge status and willingness to vaccinate enlighten the complex interplay between attitudes and personal behaviors.

Does written informed consent adequately inform surgical patients? A cross sectional study.

BACKGROUND: Informed consent (IC) is an essential step in helping patients be aware of consequences of their treatment decisions. With surgery, it is vitally important for patients to understand the risks and benefits of the procedure and decide accordingly. We explored whether a written IC form was provided to patients; whether they read and signed it; whether they communicated orally with the physician; whether these communications influenced patient decisions. METHODS: Adult postsurgical patients in nine general hospitals of Italy's Campania Region were interviewed via a structured questionnaire between the second and seventh day after the surgery at the end of the first surgical follow up visit. Physicians who were independent from the surgical team administered the questionnaire. RESULTS: The written IC form was given to 84.5% of those interviewed. All recipients of the form signed it, either personally or through a delegate; however, 13.9% did not know/remember having done so; 51.8% said that they read it thoroughly. Of those who reported to have read it, 90.9% judged it to be clear. Of those receiving the written consent form, 52.0% had gotten it the day before the surgery at the earliest 41.1% received it some hours or immediately before the procedure. The written IC form was explained to 65.6% of the patients, and 93.9% of them received further oral information that deemed understandable. Most attention was given to the diagnosis and the type of surgical procedure, which was communicated respectively to 92.8 and 88.2% of the patients. Almost one in two patients believed that the information provided some emotional relief, while 23.2% experienced increased anxiety. Younger patients (age ≤ 60) and patients with higher levels of education were more likely to read the written IC form. CONCLUSIONS: The written IC form is not sufficient in assuring patients and making them fully aware of choices they made for their health; pre-operative information that was delivered orally better served the patients' needs. To improve the quality of communication we suggest enhancing physicians' communication skills and for them to use structured conversation to ensure that individuals are completely informed before undergoing their procedures.

[Day surgery: the role and training needs of nurses]. / La Formazione dell'Infermiere in Day Surgery.

Medicine and health care are increasingly directed towards the achievement of high quality standards and of costs reduction. It is in this framework that same-day surgery finds its role, being able to satisfy both of the above needs. Despite its recognized benefits, in Italy this efficient model of hospitalization still meets several obstacles and the ratio of services provided in day hospital with respect to ordinary hospital admission is about 1 to 3. Day Surgery services depend on team work and the nurse's role is of utmost importance and responsibility since it involves both clinical care and managerial activities. Through a careful analysis of the skills required of a day surgery nurse, the authors discuss aspects of nurses' training in view of the pre- and post-graduate courses currently offered, including on-the-job training.

[Epidemiology of breast cancer in a local health organisation of Naples (Italy), 1995-2003]. / L'Epidemiologia del ca mammario nel distretto 46 dell'ASL NA1: anni 1995-2003.

A database was created by the authors to collect data on breast cancer epidemiology in a local health organisation of Naples. Data on women residing in the territory of the local health organisation and who had received a diagnosis of breast cancer, based on clinical, radiological, and pathology criteria, between 1 January 1995 and 31 December 2003, was collected through linkage of various data sources. Overall, 475 new cases were identified in women aged over 34 years at diagnosis. Though yearly raw incidence rates show an increasing trend, this was not confirmed by subsequent analysis of standardized rates. The age-specific incidence curve depicts a sharp increase from ages 30 to 50-54 years and a slower rise after the menopause, analogously to what has been shown for Europe. Standardised morbidity rates in the examined period (1996-2003) are lower than those detected by the pool of Italian tumour registries (Italian Association of Tumor Registries - AIRT) but similar to those observed by the two Campania regional tumour registries. Standardised mortality rates were found to be similar to those observed by the AIRT Pool and by the two regional registries. Age-specific mortality rates indicate three levels of risk: low-risk below 39 years of age, intermediate risk between 40-59 years of age and high risk = 60 years.

[Economic impact of healthcare-associated infections]. / L'impatto economico delle infezioni ospedaliere.

Healthcare-associated infections are not only an important public health problem but also have a relevant socioeconomic impact. The overall estimated yearly costs vary between 3.5 billion euros in the United States to 1.3 billion euros in England. In Italy estimated costs are 2.5-5.0 billion euros/year with the cost of a single case ranging from 9,000 to 10,500 euros. The present study aimed to describe the type and distribution of hospital costs for healthcare-associated infections, the economic impact of prevention programs and models for cost effectiveness evaluation of prevention programs. A review of the existing published literature was conducted; studies were included in the review according to whether they had included a control group and to the number of subjects enrolled. Healthcare associated infections lead to increased direct, indirect and intangible costs. Most economic analyses that have been performed consider only direct costs, estimated by calculating the costs of extra days of admission. Surgical site and bloodstream infections were found to be the most costly types of infections, followed by lower respiratory tract and urinary tract infections. There was wide variation in costs between individual hospital departments and countries. Control and prevention strategies have been shown to be effective and efficient but should be evaluated within a specific local context. Prevention programs should therefore take into consideration the local situation.

[Data quality of a breast cancer database in Naples, Italy. Do the necessary conditions exist for implementing a disease registry?]. / Qualità dell'informazione della banca dati del ca mammario.

Data quality is one of the fundamental aspects of health information systems and is influenced both by the type and accuracy of the data sources used. The aim of this study was to assess the quality of data in a breast cancer database held by a local health authority in Naples (Italy) and to evaluate the possibility of implementing a disease registry. The database collects information from different sources and was evaluated in terms of completeness, accuracy and comparability. Data linkage of all district data sources was performed; these included medical charts of the Integrated Territorial Oncology Service (SOTI), hospital discharge abstract forms, disability registry, list of subjects affected by specific disorders and therefore entitled to exemption from healthcare costs related to their disease, and the Nominal Registry of Causes of Death (ReNCaM). From 1 January 1995 to 31 December 2003, 475 incident cases of breast cancer were identified; 313 (65.9%) of which through the Integrated Territorial Oncology Service, and 71 (14,9%) through discharge abstract records, while only 3.6%, 4.0% and 11.6%, respectively, through the disability registry, lists of subjects with healthcare costs exemptions, and the ReNCaM. Medical charts of the Oncology Service were found to be the most complete data source for demographic information, hospital name, staging and treatments given, histologic diagnosis, and for most risk factors. By linking 178 patients registered both in the discharge abstract forms and in the Oncology medical charts, discordant demographic data, name of hospital, and date of diagnosis were found respectively in 7.3%, 16.3%, and 42.1% of cases. Overall the quality of data was found to be good and comparable to other registries. However the database cannot yet be considered as a disease registry in view of the small geographical area involved and the lack of continuous and systematic data flow; the latter can be provided only by facilities with sufficient economic resources and personnel specifically assigned to the task.

[Management of patients with cerebral stroke in Molise (Italy): MO.STRO (MOlise STROke).]. / MO.STRO (Molise Stroke): la gestione dei pazienti affetti da Ictus cerebrale.

Acute stroke patients in the Molise region (Italy) are generally admitted to an Internal Medicine or Geriatrics hospital ward. In this study all 446 acute stroke admissions which occurred in Molise in 2004 were evaluated by analysing the following data: time from symptom onset to admission, diagnosis, acute care treatment, comorbidities, disease severity, complications, disability level, mortality, discharge modality and adherence to current guidelines. Mortality was very low in the study population (approximately 8% vs. 15-17% for the rest of Italy) and was found to be related to age above 80 years, disease severity, presence of dysphagia and to being admitted to the hospital of Campobasso (a sub-analysis of this population showed an equal degree of risk in the Geriatrics and Internal Medicine Units). Forty-two percent of survivors had a moderately severe to severe level of disability (Rankin score 4-5) and went home immediately after discharge (with a major part of the burden of care resting on families). At all study hospitals, computed tomography scan was performed within 48 hours of symptom onset, as per current guidelines for the management of acute stroke. On the other hand, adherence to current guidelines regarding other components of management such as evaluation for dysphagia, placement of a urinary catheter, aspirin therapy, rehabilitation, and performance of diagnostic procedures (e.g. doppler, echocardiogram) was not uniform in all study hospitals. Several aspects of stroke management should certainly be improved, in accordance with current international guidelines, in order to provide optimal acute stroke care in the Molise region. These include: time to hospital admission (e.g. by improving the emergency service "118"), standard treatment and diagnostic procedures, physical rehabilitation services and involvement of family physicians.

[Sexually transmitted diseases: a public health issue]. / Le malattie sessualmente trasmesse:Un problema di sanità pubblica.

Sexually Transmitted Diseases (STDs) are a main problem in the public health policy. The importance of these diseases is not only limited to their high incidence but also to the complications they may cause and to their role in the HIV transmission. Control of STDs represents one of the main aims of the World Health Organization. For many years STDs were thought to have been almost completely eliminated; instead, recently the rates of STDs are increasing. This has prompted the search for control strategies, that, however, have shown to be difficult to implement. For this reason, prevention programs based on promotion of responsible sexual behaviour, early diagnosis and treatment, and reduction of infectiousness, have been implemented in many countries.

[Pilot prevalence study about nosocomial infections at the polyclinic of the naples university]. / Studio pilota sulle Infezioni Ospedaliere nellAzienda Universitaria Policlinico della Seconda Università di Napoli.

381 patients from the Naples Polyclinic - University II were submitted to a pilot study aimed at detecting the prevalence rate of hospital infections. The period examined ranges from January 1999 to January 2000 and the whole survey was aimed at detecting the extent of such infections so as to foster an infection-control system. Data have shown a 6.8% prevalence rate, with a higher risk of infection for surgical patients and those undergoing invasive procedures.

[Malaria: an Issue of Public Health] / Malaria: un problema di sanità pubblica.

The Authors have analyzed the epidemiological situation in Italy as regards malarial infections during the years 1960-1999. They paid special attention to the risk of malaria importation connected with an increased number of intercontinental journeys. The possibility of its reintroduction was assessed through the analysis of environmental and climatic factors on the Anopheles populations still living on our territory. Other infectious factors have also been analyzed (e. g. blood-transfusion). The authors suggest potential strategies for individual and environmental prevention and stress the need for better information activities.